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Monday, 29 August 2016

Gerd Gigerenzer, Director of Harding Center for Risk Literacy at the Max Planck Institute for Human Development in Berlin, has published "Risk Savvy. How to make good decisions" (Penguin 2014). It’s a book that addresses the difficulties of making decisions in uncertain environments and the need to know how to communicate risks in an understandable way. According to the author, according to his own experience, 80% of doctors do not understand the meaning of a positive result in a diagnostic test and, following this line, in an Australian study, from the 50 doctors surveyed, only 13 responded that they understood the concept of "positive predictive value" (which is the probability of having a disease if a specific test is positive), but only one of them finally was able to explain it properly. In a post on this blog, "Too much mammography or the mirage of screenings", Cristina Roure said that a woman's risk of breast cancer after showing a suspicious lesion on a screening mammogram is 10%, when most doctors believed to be 90%. After this introduction, we can understand why we ought to consider Gigerenzer’ book as essential in medical practice in a world of probabilities.

Monday, 22 August 2016

A few months ago, Josep Maria Monguet published a post on this blog about the low cost medicine in India, and along these lines I thought it would be interesting to comment on an article by Atul Gawande in the New Yorker with some comparative reflections between medicine and restaurant chains. "In medicine -says Gawande- try to provide a wide range of services to millions of people at reasonable costs and an acceptable level of quality, but the reality is different: the costs continue to rise, the service we offer is mediocre and the quality, uneven. Each doctor has his own way of doing things and the variations in the results, even within the same health centre, are inexplicable.

Dave Luz, regional manager at the Cheesecake Factory in the Boston area, explains to Gawande that his mother, with advanced Alzheimer's, fell down at home the other day and has been taken to the emergency room, where doctors visited her, did various tests and kept her under observation for the night. Luz received three types of explanations: from the emergency physicians, from the internist at the observation room and from a specialist, and these were not exactly coincident. He soon realized that there was no plan involved there. The next morning, a nurse told him that his mother was fine and that they would prepare her for discharge but because the nurse in charge was having her breakfast, they would have to wait, and that process, seemingly bureaucratic lasted until the afternoon because the doctor who had to make the discharge report could not be found. To cap it all, when it was time to dress his mother, the auxiliary disappeared and Luz had to fend for himself. With the discharge papers, he would schedule a control visit to collect the results of urine tests and one to see a neurologist. A couple of weeks later, the neurologist, after an examination that lasted a couple of minutes, called for new tests (by the way some matched those that had been made in the emergency services) and prescribed some medication that, once asked what they are for he admitted they‘re useless. Dave Luz says that this kind of disorganization among professionals and circuits, this lack of an overall plan, was to be found everywhere where he had to go to accompany his mother for receiving medical care.

Monday, 15 August 2016

Hospitals are structures that generate a powerful influence on the overall health system. Their effectiveness in the resolution of certain acute diseases, especially surgical, gives them a great social prestige. This fact should not, however, hide two structural problems that are burdening their perspective:

a) The first problem is internal. Bureaucracies themselves are showing signs of fatigue and this affects the quality of services, especially in the safety of admitted patients.

Monday, 8 August 2016

Readers of the blog Advances in Clinical Management will be familiar with the term Triple Aim coined by Donald Berwick from the Institute for Healthcare Improvement of the United States(1) which recognizes those clinical projects that simultaneously achieve the triple objective to:

Monday, 1 August 2016

In an article in Harvard Business Review, Fixing Health Care on the Front Lines, Richard Bohmer presented the three pillars of modern clinical management (see post: Clinical management as a mechanism of change). I like Bohmer’s contributions because he always looks at what can be done to bring the concepts to the real world, so it has seemed appropriate to comment on another one of his articles published in NEJM, The Four Habits of High-Value Health Care Organizations, which raises the logical point: if you want to encourage high value clinical practices, high value health organizations are paramount and for this reason, the author has studied the ways of working of the US healthcare institutions that are showing the best results in clinical and cost effectiveness (referencing the outcomes of Michael Porter) and he extracted 4 habits that, according to him, should be exportable: